SUPPORT SERVICE UNITS

Medical Records This is one of the important departments in the hospital. The patients records (case records, X-rays etc.,) are valuable not only to the patient but also to the doctor and to the medical education and research. Laboratory Laboratory is the base for the diagnostic tests. Medical conditions are diagnosed partly on diagnostic tests. Laboratory technician performs these tests. One laboratory technician can do approximately 35 tests per day. He can do 45 hematology tests, 50 urine analysis tests, 50 parasitology tests /or blood bank tests/or serological tests/30 biochemistry tests and 20 histopathology tests. Note: These figures are relevant if the technician is asked to do just one particular type of test.If he has to do a normal mix tests,he should perform approximately 35,as mentioned.It depends also on the methodologies practiced in the laboratory for various investigations. Also required are one section head over 7 laboratory technicians, clerical staff and bottlewashers, keeping in view the workload and technology used in the department. Laundry The number of personnel required in the laundry department depends upon the frequency of changing the linen In the wards, the quality of linen, as well as upon its laundry equipment-whether it has boilers, washing machines, hydro-extractors, drying tumblers, flatwork ironers, flat bed presses and allied equipment. However, one laundry operator can wash the linen of 50 to 60 beds and one laundry orderly can assist in washing the linen of 50 to 60 beds.30 % of laundry operators and laundry orderlies should be kept as leave reserve. The appointment of laundry supervisor, mechanic and clerk, and the number employed depend upon the size of the hospital.The staffing norm based on, One washer man can take care of 150 to 200 kgs per day. Each operation in OT 7 to 8 kgs of soiled linen Each delivery in LR 7 to 8 kgs of soiled lien Each ward patient 5 to 6 kgs of bed linen.

Dietary

The dietary or food service department of any hospital caters meals to the patients and plays a significant role. Meals prepared hygienically under the guidance of qualified dieticians, according to the instructions of the doctors and attractively served to the patients help in their speedy recovery. Generally in the food service department of a hospital the dietician,food store keeper, cook helpers ,bearers and dishwasher works in close collaboration. One dietician can look after upto 200 beds.If the bed strength exceeds 200 beds, another dietician should be appointed. One cook,one cook helper,one bearer and one dishwasher are sufficient to prepare and serve meals for 20 patients/staff members.The food is served to the patients in their wards and to staff members in the hospital cafeteria. A 30 % leave reserve should be appointed,because the food service department functions round the year. CSSD (Central Sterile Supply Department)

To improve hygiene, and to reduce spread of infection caused by pathogenic microorganisms hospital have over the years developed a scientific and effective method commonly referred to as central sterile ad supply system. The method basically involves cleaning, disinfecting and sterilizing before use all instrument, materials and equipment utilized in parent care. Surgical instruments, clothing and equipment in particular demand different sterilization and handling procedure to promote a germ free environment. These efforts are complemented the design of the facilities that separates unclean, clean and sterile zone by means of barriers and two doors, pass through washer disinfectors and sterilizer that placed in the barrier walls. From the various part of the hospital such as the operating rooms, wards and clinics, soiled or infected items are brought to the CSSD where the process of cleaning, disinfecting, inspecting, packing, sterilizing, storing and distributing is carried out by specially trained personnel under sterile condition. The sterilized items are ten returned for reuse in their respective departments, In some hospitals CSSD does only autoclaving. The rest of the sterilization process takes place in their department itself. For example small and medium hospital instrument, surgical packs, tray etc. sterilized by autoclave. Rubber, PVC and plastic article, plaster, catheter, pace maker are heat sensitive; they are sterilized by ethylene oxide or similar gases. But we should be aware that gas sterilization requires more precaution like aeration, exhaust, separate room etc. Traditionally, central sterilization has been a function and part of nursing department. In most of our hospitals we also found that the sterilization unit or department is located next to surgical suite. But trend is regarding CSSD for the entire hospital. It is not part of nursing department or surgical suit any more. DISADVANTAGES OF DECENTRALIZATION

Duplication of sterilization of the equipment. Necessity of having additional staff in there section Supervision and standardization are difficult. Wastage of nurses time Chance of negligence behavior causing false sense of security Chance of accident if safety precaution are not observed Reluctance on part of other staff to handle additional work load Higher expenses to hospital due to 1. Duplication of equipment 2. hidden cost of improper sterilization 3. risk of hospital acquired infection 4. longer stay in hospital 5. high risk of morbidity/mortality Advantage of CSSD:1. Sterilizing of instrument and material is done by specially trained personnel using integrated system under controlled condition. This contributes to total environment control in hospital. 2. Keeping and operating the expensive equipment in one central place achieves greater economy. 3. The hospital can achieve a uniform system by standardizing procedure and technique of operation. 4. A high level of efficiency will be achieved in sterilizing by training personnel in the correct processing techniques and procedure. 5. The facilities for cleaning in a central supply room are more adequate and effective than is possible on the word. 6. Sets and trays which are prepared centrally are uniform and comply with establish nsg procedure. 7. The exact amount of dressing towels and other supplies are provided hence waste is lessened. The disadvantage of CSSD id the possible delay in obtaining material if everything is centralized. However this can be fairly well overcome by having each ward stop with supplies and sets sufficient in number to meet daily requirement. Activities of CSSD:1. Receive soiled and unsterile from different department of hospital. 2. sorting out these items Whether the items need to be discarded. Whether the item is reusable ex: - if torn gloves broken syringes cracked catheter are received they are discarded.

3. Preliminary cleaning with water and disinfectant to clean out contamination. [used and soiled linen is first rinsed in water by used department and dipped in a plastic drum containing 2% sodium hypochlorite solution for disinfection. If use department follow it work of CSSD becomes easier because if blood, pos or any other biological fluid dries up, it is difficult to remove the stain.] 4. It any item requires specialized method of cleaning then the same is carried out. 5. Instrument, parts of equipments, tubing, linen etc. are thoroughly checked to decide whether any repair is required. If so necessary actions are taken. 6. Dressing packs, linen packs, trays for specific procedures, instrument are assembled and arranged. 7. Sterilizing is carried out after packing the assembled items in suitable package. 8. After putting labels and waking entry in the supply register sterilized material is sent to the respective areas. PRINCIPLES OF DESIGN CSSD:In the design of the CSSD, the important principles the planner and the architect should bear in mind are the following:1. The traffic and flow of flow of work is continuous from receiving where the soiled items commence their journey to issuing where the sterilized items are issued, without retracting steps. To accomplish this purpose, there should be a separate entrance to receive soiled items and contaminated materials, and another area for issuing clean and sterile supply. The receiving, cleaning and decontaminating area is physically separated from the rest of the department. For most application cleaning is necessary first step. This is followed by the next steps, a process of disinfection or decontamination, before sterilization. In an ideal set up, there are three compartmentalized areas soiled area, clean area and sterile area. These are separated by means of barrier walls and double door; pass through machines embedded in walls. in the clean area ( middle comprt ) , sorting , inspection and packing of the clean and disinfected material take place before they are loaded into autoclave (double door ) placed in barrier wall b/w clean and sterile area.

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Situation, area and planning:For minimizing distance for transportation and also for saving time, CSSD should be located as near main user area as possible. Operation theater, ICU, and wards consumes wore materials. Therefore keeping in mind these requirements CSSSD should be on the same floor immediately

above or below. Requirement of area depends mainly on work load, number of sterilizing equipments and turn over the material. Minimum area requirement is 7sq. ft. per bed, or minimum area of 100sq.ft. if the hospital is small keeping in mind likely increase in future workload, its advisable to have a little bigger area so that expansion is possible. LOCATION: near casualty / ward unit or labor room Where adequate supply of water, steam and electricity

FLOOR SPACE: - it can be divided into six basic units A B C D E F total Clean work area including sterilization area Sterile storage Equipment storage Fluid, needle, syringe Reception and clean up area Gloves processing area 40% 15% 14% 12% 12% 7% 100%

AREA PLANNED:500 beds- 2000 sq ft 1000 beds 3500 sq. ft. 75-90 beds- 10 sq. ft. per bed 300 & above 7 sq. ft. per bed CSSD also has well defined zones (like O.T.) These zones are 1. area for soiled item 2. clean area 3. sterile area

1. Area for soiled item: - when used or soiled items are received they are cleaned in this are using water and disinfecting solution. Although necessary human traffic is not desirable, there is no restriction for entry in this area. Concerned staff only can enter this area freely. 2. Clean area; - in this area CSSD staff only permitted. The activities includes inspecting ; sorting out, discarding and packing the material in trays, drums, baskets as per specific procedure doer autoclave. Door facing clear area is in door of autoclave and the door facing sterile area is exit door for removing sterilized items. Autoclaving can done by moist hast /formaldehyde / ethylene oxide. CLEANING DRYING AND PACKING: Cleaning can be done by Manually, by machine , or by ultrasonic energy or high pressure water jet machine ( cleaning 100 instruments with in 3 minutes) Drying oven and infra red moving belt drier can be used which dries with in 10 min Catheter tubing should soak for 4 hrs before washing with warm water with adkahest Gloves can be washed with any above technique (before washing look for tear, puncture by water air. Dries repair and powdered and arrange with size and at last pack in disposable paper) Needles should be tests for sharpness before wash with ultrasonic cleaner. The blocked needles should discarded The packing of the equipments depends upon the technique of sterilization like for steam can use linen or paper and for hot air sterilization suitable container made of glass, aluminum, or steel. The advantage for individual packing is: Quick pack More economical Simple for all Flexible Easy to separate for steam or hot air 3. Sterile area: - sterile area is used for unloading sterilized items. The activities included are receiving are, area for sorting out items, washing and disinfection area, area for packaging, sterilization area cover autoclaves are placed, sterile storage area and issue counter, facilities for staff office- staff room , changing room , staff toilet , supervisors office glass wall for visibility The sterilization consists of six possible methods which are as follow :a. steam

b. hot air c. boiling water d. gas e. gamma radiation f. chemical fluid The factors determining methods of sterilization are: Type of material Possible damage of material Methods of packing] Availability of equipment Work load and cost involved

Fig: - conceptual diagram of CSSD. Item sterile (Out) Sterile items

Clean area Soiled item (In) Soiled area

Personnel: Staffing depends upon following factors: Scope of function Schedule hours of service Methods of distribution and collection Physical facilities and processing equipments

At least one employee for 30 beds( there is no criteria or standard has developed for required staff)

The required staff is as follow:A. manager or supervisor: - science graduates who is well acquainted with (a) microbiology (b) methods of sterilization (c) routine pt case given in different departments (d) personnel manager B. Technicians: - these members can be picked up from other areas and trained to carryout work of CSSD. (Concerned with sterilization) C. Assistant: with pack washed and disinfected materials in trays, drums, packs etc. They help technician in carrying out sterilization. They also take care of sterilized material. Storing and issuing sterile material is done with the help of assistant. D. Attendant: accept used and soiled material in soiled area. They carry out washing and disinfection. Also help assistant and technician in packing and loading autoclave. Some also required for storing and transporting. Attendant working in soiled area continue to work there, for specified period. They should not simultaneously work in clean area also. REQUIREMENT OF EQUIPMENT AND ACCESSORIES:1. Equipment required for washing and disinfecting soiled and used items. Ex. Soaking sinks high pressure water jets, needle cleaning device, and ultrasonic washer 2. Items required for packing: steel topped or marble topped platform or table for working. Folding linen Cutting gauze Packing dressing material Preparing procedure tray etc. 3. Sterilizing equipments Double door steam sterilizers (autoclave) Chemical sterilizer- ethylene oxide gas 4. Furniture for staff: 5. Storage facilities for storing sterilizing items. Others: SS workable wit wastage bin Worktable with under shelf Vertical sliding door

Single free standing basket rack Storage shelf Work table with 1/2/3 sink Glove washer/ dryer/ powders/ storing bins Trolley with carriage Water still Double free standing basket rack

HOSPITAL INFECTION CONTROL COMMITTEE Hospital infection control committee should have very active very active role in deciding the routine and the policies of CSSD. These include: a. b. c. d. e. methods of transports instruction to users regarding transport of soiled items sterilization methods to be used ensuring safety and efficiency of sterilization process decides methods of monitoring quality Color index strips Random culture from sterilized items Actual process implemented by staff decide on distribution methods and quantity fixed quota exchange of sterilized items against soiled items decide on shelf life of sterilized materials in case of reported infection, trace back the likely source of infection and implement corrective steps proper regulation and rotation of staff material management staff management Skill training of staff members regarding any new technology etc.

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FINANCIAL CONSIDERATION: The costs of establishing CSSD are two types 1. Capital cost: cost of premises, processing and other equipment and extra equipments 2. Running cost: labor for processing and packaging

 dressing and packaging material maintenance of equipment cost of distribution and collection The overall cost depends upon: Size of hospital and scope of services Availability of space and location Type of equipment Various policies and procedure Total stock required amount to 4-5 times the average daily usage.

JOB RESPONSIBILITIES OF THE NURSE 1. Collects, decontaminates, cleans, assembles wraps, sterilizes, labels and stores patient care supplies and equipments according to established protocols and standards. 2. Maintain adequate level of processing materials for preparing supplies for sterilization. 3. With assistance, and establishes inventory and stock level for preparing supplies for sterilization. 4. Report all the malfunctioning equipments to the concern person. Remove item from services/ tag them for repair. 5. Provide patient care area with a wide variety of supplies and equipments, instruments, trays and sets. 6. Anticipate need and order needed supplies and equipments through periodic inventory and discuss with supervisor. 7. Use standard precaution and correct personal protective equipments. 8. Assist nursing management in regular and on the spot performance improvement activities. Accounts ( Business office) This department has the responsibility for collecting the money which is owed to the hospital,paying for the supplies and equipment,handling all records pertaining to hospital finance,keeping records of assets and liabilities and assisting with budget.The business manager is responsible for the functions of this department.The accountants help him. Billing The billing department has the responsibility for billing and purchasing all supplies and equipment for the hospital.

 Blood Bank It has the responsibility for collecting and processing all blood used in the hospital for transfusions.It makes studies on newborn infants who may have hemolytic diseases and does antibody studies on the prenatal patients. Computer Section Technological applications in the 20th century have benefitted many facets of human activity. One of these technological applications is the computer.Computer is a technological aid in gathering information, storage, retrieval, processing and in making decisions. Objectives of Computers in health care institutions: Improve efficiency at work Improve the services to the clients Provide better professional care to the clients Improve profitability Prevent losses due to errors Provide the management with planning and control information Efficient utilization of staff and resources Effective time management Enhance the image of the establishment There are many ways to look at computer system in hospitals. Computerisation in medical establishment can be divided into two broad areas. 1. Administrative 2. Clinical Administrative Every health care institution will have a substantial amount of administrative work for which a computer is ideal. The administrative applications include : Billing Inventory control Financial Accounting Correspondence Medical records Clinical

The clinical applications help the doctor in his or her professional work.For example the clients case sheet,generation of prescription,immunization schedule,dosage calculations, antenatal follow ups and ECG analysis.Computers are of great help in : Professional writings and presentations Continuing medical education E mail and Internet access Research Entertainment and family use

Nursing service Computer applications Computer application can enhance quality of care to optimize productivity. Computer can help in the following areas: Planning nursing care: Since each patients and wards nursing needs are different computer can assist in effective planning. For each patient a nursing care plan can be constructed which will have all information about the health history of patient, medicines to be administered,dosage,diet,therapies.This will help the physicians and surgeons,besides the nursing personnel to enhance the quality of care. Monitoring and interpreting physiologic variables: In the last few years ,many patient monitoring devices have been developed. In the western countries,technological development in this field are being developed at a very rapid rate,computers and micro processors are part of all patient monitoring services.Cardiac rhythm monitoring is the most common.The most complex in these is sampling arterial blood gases and based on the results adjusting oxygen concentration,frequency or tidal volume of the ventilator. Administering medicines: Computers can assist in calculation drug dosages against the patient age, weight and body surface area,emergency drug doses for patient can be prepared,starting resuscitation administering continous IV infusion. Patient classification system : Patients can be easily classified as to their acuteness with the help of the computer.Based on this number of nursing personnel required can be computed.This can be worked out for each shift or as per the needs of the institution. Scheduling staff : Work schedule can be prepared keeping in view the inpatient and outpatient load acuteness,number of operations to be performed or camps to be conducted,location of health centres,staff locations,preference for shifts or availability of the consultants on certain days,policy guidelines and related factors.

Record keeping : All ministrations,discharges,materials,equipment,personnel,payroll, Insurance, billing, inventories, referrals and all other information can be easily handled by the computer.